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County <br /> Safety and Buildings Division of <br /> TN 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P$ � Madison,WI 53707-7162 <br /> C1 <br /> Sanitary Permit Application State Tr tio,/nNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit N.y�/ UI <br /> is required prior to obtaining a sanitary permit. Note.Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary / <br /> purposes in accordance with the PrivacyLaw,s. 15.04(I)(m),Stats. ��� //�/• <br /> 1. Application Information-Please Print All Information Anil <br /> Property er, N Parcel is - <br /> qu� //`Op -oae-7,40 6 i2-5-B5wn i cn <br /> Property Owner's Mailing Address Property Location 4 GL- <br /> 64M <br /> 6 !/ O r#9 i/ Gw.Lot <br /> City,State Zip Code Phone Number z <br /> '/., '/., Section�_ <br /> 01V PZ-75/- 14 (3 �N; (circle on <br /> R� <br /> H.Type of Building(check all that apply) Lot N TEo& <br /> 191 or 2 Family Dwelling-Number of Bedrooms Z 1 Subdivision Name <br /> Block H <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 50 VG l.W *Townof em"A <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑ New System �`Re lacement System <br /> ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> pr Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) stem Elevation <br /> y� yz� 9y6 d�yo <br /> VI.Tank Info Capacity in Total k of Manufacturer <br /> Gallons Gallons Units <br /> a U - <br /> NewTanks Existing Tanks <br /> o. U v, G <br /> Septic or Holding Tank �1LTx t• \/' <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu r Name(Pri ) Plu r Signature MP/MPRS Number Business Phone Number <br /> 55? ti ✓9 r�,) <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z72Zo ,Win, INa Gil Sl/ <br /> VII Coun e artment Use Only <br /> Approved /D❑ Disapproved Permit Fee Date Issued Issuing A ignature <br /> ❑Owner Given Reason for Denial <br /> 3125g' z9T��1a <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x 11 inches in size <br /> SBD-6398(R. 11/11) <br />